Alumina-on-alumina total hip arthroplasty has been used for 32 years in Europe. The theoretical advantages of this combination are represented by its remarkable sliding characteristics, its very low wear debris generation, and its improved fracture toughness. These advantages are achieved if the material is processed properly with high density, high purity and small grains. We summarize the results obtained with the alumina-on-alumina combination concerning in vitro and in vivo wear behavior with special emphasis on wear debris characterization and quantification and histologic tissue examinations. Alumina-on-alumina seems to be one of the best choices in young and active patients provided that sound socket fixation is maintained in the long term.